The extent and impact of implementation of youth friendly sexual and reproductive health services in Nepal: a mixed method examination

Background: Adolescent and Youth Sexual and Reproductive Health (AYSRH) is a vital aspect of their overall well-being, encompassing issues such as preventing unplanned pregnancies, STIs, and sexual violence. Nepal faces challenges in providing comprehensive AYSRH services due to cultural, social, and economic factors. Despite commitments to address AYSRH issues, Nepal struggles with high rates of child marriage, adolescent pregnancies, and limited access to contraception. Realizing the issues in trying to reach adolescents and youth and to improve sexual and reproductive health of young people, Ministry of Health and Population of Nepal developed the National Adolescent Health and Development Strategy 2000 which was revised in 2018.The government has implemented initiatives such as Adolescent Friendly Health Services (AFHS) to improve access to AYSRH services, but challenges persist, including stigma and discrimination. According to WHO, AFHS are evidence-based programmes to ensure excellent healthcare services for adolescents that are “accessible, acceptable, equitable, appropriate, and effective”. The focus of the AFHS is to satisfy the health needs of all adolescents, irrespective of sex, religion, impairment, societal position, or additional factors. AFHS refers to the atmosphere and situation in which adolescents can conveniently access and use health information and services that they require in a friendly way without any discrimination. Healthcare providers have a major role to play in providing these services to adolescents and youths. Health Service Providers (HSPs) contribute as agents of change in their communities as they influence the community to take adolescents' health seriously. Methodology:A mixed method study design was used in this research to understand and explore the topic in depth. Relevant literature and document review on friendly health services for young people; an in-depth interview with health service providers followed by secondary data collection at AFHS and workshop with youths. Lalitpur and Bhaktapur district in Nepal is purposively selected for conducting the study as AFHS are available in both the districts. People included in the study were health service providers working in AFHS and youths aged 15-24 living in the study area. Ethical clearance was taken from Ethical Review Board of Thammasat University and Ethical Review Board of Nepal Health Research Council. Purposive sampling technique was used because this study is particularly focused on SRH of young people. Two public and two private facilities providing youth friendly health services in each district were selected after contacting government and private organizations. In-depth interviews with eight health service providers, one from each AFHS, was taken. Two workshops comprising of 6-8 youth in each workshop was purposively selected based on those who have not used AFHS in Lalitpur district and those who have used AFHS in Bhaktapur district. Reflexive thematic analysis was used for data analysis. The main data analysis strategy was to compare the findings of this study with international literatures and Nepal’s AFHS program guidelines; the services being provided by public sites and private sites; and perception of health service providers vs youths on AFHS. Findings: Altogether, in IDI, there were eight health service providers ranging from age 35 to 59 years. Among them, five were female and three were male. Likewise, there were a total of 14 participants in two workshops belonging to age 15 to 24 years. There were nine female participants and five male participants in the workshop. The seven key themes emerged from the study are: 1) provider’s competencies, 2) provider’s characteristics, 3) health facilities features and services, 4) current AFHS practice, 5) barriers for delivering AFHS services and barriers affecting the use of AFHS, 6) effect of COVID-19 on delivering SRH services and 7) recommendations from HSPs and youths on making the services youth-friendly. The AFHS were mostly being provided at health posts in public facilities while they were being provided at I/NGO run clinics at private facilities. It was found that the private facilities were more forward in terms of providing trainings, refresher training to health service providers and peers than the government run facilities. The selected HSPs were doctors/nurses/health assistants who were directly involved with delivering service to adolescents and youths. Majority of them (six out of eight) had received an orientation or training on proving AFHS. Both the HSPs and youths revealed the HSPs should be well trained, have good knowledge on SRH, ensuring client’s privacy and confidentiality, non-judgmental attitude, understanding, respect client, friendly, good counselling and communication skills for an effective and quality AFHS. The perspective of youths on youth friendly health facilities was accessible location, offer a friendly environment, private/separate rooms, gender friendly HSPs with the availability of services such as free contraceptives, free pregnancy test, blood test, abortion services along with proper counselling, accurate information, awareness programs including health camps, affordable and referral services. The interview with HSPs clearly revealed the current practices guided by the international best practices and national standards and as per the resources available. This includes maintaining the privacy and confidentiality of the clients, equal and non-discriminatory behaviour towards the client, creating a friendly environment, proper counselling and provide accurate information and services as per the client’s demand along with conducting school health programs. The HSPs working in FPAN also mentioned about training peer educators and mobilizing them in the community. The public health facilities were providing services free of cost while the private facilities took minimum cost. IEC materials were not available at most of the health facilities as reported by the service providers. The most common services being provided and used at the adolescent friendly health services for youth group were family planning or contraceptive services, followed by safe abortion, STI screening and counselling/consultation as reported by the HSPs. The services were provided equally and without any discrimination to all the adolescents and youths despite their age, gender and marital status as responded by all the service providers. The HSPs working in public facility reported conducting school health programs once or twice a year where they would take awareness generating classes in adolescent groups while HSPs working in private facilities conducted awareness programs in schools and community, trained peer educators and mobilized them. Many barriers were revealed by the HSPs for delivering SRH services. It mentioned problems like not having enough space, not getting support from the government authorities, not having enough staff, no budget allocation, unavailability of IEC materials and struggling to put training into action. Furthermore, the factors affecting youth’s visit to AFHS such as fear of judgment, societal stigma and privacy concerns when accessing healthcare services, largely due to negative attitudes exhibited by many health service providers, lack of awareness/knowledge on existing AFHS was revealed. The youths visiting the facility was very low since the nation underwent strict lockdown but the overall client flow was high as mentioned my most of the HSPs during the pandemic. The HSPs and youths provided a wide range of recommendations on making the existing services more youth-friendly. They suggested providing necessary trainings to health professionals/teachers/peers, promotion and marketing of AFHS using right means/creating websites, allocating budget, following evidence-based practices, integrated approach, advocacy, increasing youth as well as school participation and conducting awareness programs. Recommendations on the components of AFHS were also given by the participants. Conclusion: Overall, the findings underscore the preferences and perception of youths on youth friendly services in terms of provider’s characteristics and health facility, barriers to implement AFHS and barriers from the youth’s side as well as recommendation on making the existing facility youth-friendly. It is imperative to prioritize the creation of supportive, non-judgmental healthcare environments, improve access to comprehensive SRH education, and implement systemic reforms to ensure equitable access to AFHS for all youths.